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D.U.E. Endoscopie opératoire en gynécologieClermont-Ferrand 13-17 Dec 2010

Carlo Di StefanoDipartimento materno infantile OPA

(ospedale pediatrico apuano)- Massa, Tuscany - Italy

Diagnostic Office Hysteroscopy

History…

Hysteroscopy was born in early ‘80 thanks to J. Hamou whodeveloped an eclectic instrument by which it was possible tolight uterine cavity, allowing to observe the morphology in itsg y, g p gyminimum details

Since than hysteroscopy has growth in its indications andclinic applications

Nowadays, the diagnostic hysteroscopy is addressed in-officesetting, with a poor cases undergone anaesthesia, minimumsurgical traumatization, and better patient compliance

Technique…

Hysteroscopy allows to observe uterine cavity by gas(CO2) or liquid distension, thanks to a cold light source, unvideo camera, and rigids or flexibles metallic optics, g p

The detailed observation of endometrial cavity, give thepossibility to execute orientated biopsies of suspectedtissues for hysto-pathologic examination

Operatives possibilities have been added in the lastten/twelve years

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WHY• INDICATIONS THAT LEADTO O.I.

OFFICE OFFICE HYSTEROSCOPY:HYSTEROSCOPY:

Why Why ??How…?How…?

Where…?Where…?Who?

• 1) Abnormal uterine bleeding (~ 2/3 of cases) concerning also endometrial formations

• 2) Infertility• 3) Follow up of oncological patients

Indications…UterineUterine bleedingbleeding representsrepresents certainlycertainly thethe mostmostfrequentfrequent symptomsymptom characterizingcharacterizing uterineuterine cavitycavitydisfunctiondisfunction

moremore thanthan 5050%% ofof gynecologicalgynecological consultationsconsultations areare forformetrorragiesmetrorragies (among(among womenwomen duringduring menopause)menopause)metrorragiesmetrorragies (among(among womenwomen duringduring menopause)menopause)

Indications…

Uterine bleeding shows different meanings according towomen age

Hysteroscopy is characterized by different indications according the age

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The introduction at start of 90’ of news hysteroscopes was the way to reduce the diameter of the instrument and improve the number of hysteroscopists and number of hysteroscopies

Thanks to these innovations it’s possible performing Thanks to these innovations it’s possible performing hysteroscopy with an instrument complete of operative hysteroscopy with an instrument complete of operative channel and continous flow system with a total channel and continous flow system with a total diameter of diameter of 55 mm or mm or lessless

In a few years the management and treatment of “simples” endocavitary

problems are deeply changed

•The surgeon is provided of a “almost”perfect instrument for diagnosis

• He is able to examinate the endometrial cavity and produce• He is able to examinate the endometrial cavity and produce a directed sampling under vision in the area of mucosa he had pointed (suspected areas)

• Moreover it’s possible to see and treat intracavity benigns pathologies without, normally, anesthesia or oral drugs

HYSTEROSCOPY EVOLUTION- From 1982 to 2010 -

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GENERATIONS

DIAGNOSTIC HYSTEROSCOPY- Gas- Anaesthesia- Hospitalization

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3

DIAGNOSTIC-OPERATIVE HYSTEROSCOPY

OFFICE HYSTEROSCOPY

- Liquid distension media (electrolitic solution)- General anaesthesia- Post-operatory hospitalization

- Liquid distension media (isotonic solution)- Outpatients setting feasibility- Reduced invasivity and best compliance- See and treat

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600

700

800

900

1000

HYSTEROSCOPY EVOLUTION4 SECTIONS OF GYNECOLOGY (SANTO BAMBINO HOSPITAL - CATANIA)

HYSTEROSCOPY EVOLUTION4 SECTIONS OF GYNECOLOGY (SANTO BAMBINO HOSPITAL - CATANIA)

OFFICE OFFICE

HYSTEROSCOPY HYSTEROSCOPY 5 mm5 mm

I GENERATIONI GENERATION II GENERATIONII GENERATION III GENERATIONIII GENERATION

IV GEN.IV GEN.

0

100

200

300

400

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600

1982 1983 1984 1985 1986 1987 1988 1999 2000 2001 2002 2003 2004 2005 2006

CONTACTCONTACT

HYSTEROSCOPYHYSTEROSCOPY

HAMOU IHAMOU I

HAMOU IIHAMOU II

OFFICE OFFICE HYSTEROSCOPY 4,2 HYSTEROSCOPY 4,2

mmmm

HOW MANY?• Unknown exatly

• Expert opinion ( Gubbini,I)speaks about 80% of endoscopics procedures are hysteroscopies

• Could be four time easierperform a hysteroscopythan a laparoscopy

•HOW( get into the uterus)

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INSTRUMENTS

• Many instruments are developped to get into the uterine cavity

• Let’s see the most common utilisedLet s see the most common utilised

Office hysteroscopy is normally performed by an operative continue-flow microhysteroscopy with 5 mm full diameter with a “rod lens” system of 2.9 mm diameter

Both hysteroscopes are characterized by oval section and are provided by two outer sheaths (flow devices) and an operativeBoth hysteroscopes are characterized by oval section and are provided by two outer sheaths (flow devices) and an operativeprovided by two outer sheaths (flow devices), and an operative channel for 5 fr instrumentsprovided by two outer sheaths (flow devices), and an operative channel for 5 fr instruments

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TO ACHIEVE THE BEST RESULTS IN TERMS OF SAFETY AND SUCCESS IT’S MANDATORY TO

HAVE A

PERFECT KNOWLEDGE OF THE INSTRUMENTS UTILIZED

OFFICE OFFICE HYSTEROSCOPY:HYSTEROSCOPY:

WhereWhere…?…?

OFFICE HYSTEROSCOPY

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OFFICE OFFICE HYSTEROSCOPY:HYSTEROSCOPY:

Why ?Why ?How…?How…?

Where…?Where…?and…..and…..

WhoWho ??WhoWho…?…?

Outpatient should be placed separately by operating theatre, in a confortable setting with smooth

colours, absence of noises avoiding confusion and , gpresence of too much professional figures

The possibility to improve the success of the hysteroscopic

examination, in terms of results and compliance, should be the

interaction with the patient, based on a clear, calm and peculiar explication of the procedure,

focusing on the several advantages offered by the “in-office” approach

and the possible complications, usually minor and generally not

harmful

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LIGHT SOURCELIGHT SOURCE

IRRIGATION SYSTEMIRRIGATION SYSTEM

OFFICE OFFICE HYSTEROSCOPY:HYSTEROSCOPY:

Outpatient Outpatient setting setting d ti td ti tand patientand patient

placementplacement

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GOLD STANDARD of HYSTEROSCOPY TODAY

IN-OFFICE HYSTEROSCOPY

• Once the instruments are setted, the procedure starts normally in vaginoscopy

• Speculum or Pozzi devices are nor necessary

• Find the posterior fornix is mandatory. It’s the start point leading to the cervix

• Once in the cervix push carefully the optic through the length of the endocervix

• It’s important get every kind of information from the vagina and cervix mucosa

• Discussion with patient …

GOLD STANDARD of HYSTEROSCOPY TODAYIN-OFFICE HYSTEROSCOPY

• The hand should be hang on a 6 hours position(according to uterus anteversion)

• Passing trought the internal uterine orifice could be painful and evoke vagal reflexes

• Waiting a little to distend the structure could avoid thatWaiting a little, to distend the structure, could avoid that

• Turn the hysteroscope of 90°(not the camera)

• Use micro-instruments if necessary

• Once inside the uterus the inspection have steps well codified:

- distensibility of cavity

- endometrium aspect and distribution

- orifices of internal fallopian tubes

GOLD STANDARD of HYSTEROSCOPY TODAY

IN-OFFICE HYSTEROSCOPY

All anomalies could be noted and, if possible, treated,

using 5 ch operative channelusing 5 ch operative channel

“see and threat”

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GOLD STANDARD IN-OFFICE HYSTEROSCOPY

An endometrial biopsy should be performed (if possible always in menopause)

Under direct vision if indicated (minimal tissue quantity required)required)

or …

Pipelle

Novak etc..

WHAT IT’S POSSIBLE TO OBSERVE AND TREAT (1)

Endometrial biopsyAdhesions (Asherman syndrome)Lost IUD (ablation)( )

It is enough to turn 90° the optic on the endocamera to orient the principal longitudinal axis on the endocervix trasversal axis

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WHAT IT’S POSSIBLE TO OBSERVE AND TREAT (2)

• IUD, ablation• Instillation of medicaments• Tubal sterilisation

GOLD STANDARD in OFFICE HYSTEROSCOPY TODAY

In terms of results• Explain clearly the procedure• Setting of the patient• Period (according to menses)( g )• Screening?• Patient preparation (misoprostol)• Respect the procedure• Time consumed

Flexible or rigid endoscopes for outpatient hysteroscopy ?

• Flexibles devices not studied for operatives hysteroscopy and expensives

• Rigid hysteroscopes provide superior optical qualities and permit a more rapid performance with higher success rates

Unfried G. et al Flexible versus rigid endoscopes for outpatient hysteroscopy: a prospective randomized clinical trial -Hum Reprod. 2001 Jan;16(1):168-171

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Success rate of office diagnostic hysteroscopy

• Less pain(max 4/10), better visualization (score 0 to 3) and higher success rates were observed with mini-hysteroscopy

• Importance of patient parity and surgeon experience

• Mini-hysteroscopy should always be used, especially for inexperienced surgeons and when difficult access to the uterine cavity is anticipated

• Campo R. et al Prospective multicentre randomized controlled trial to evaluate factors influencing the success rate of office diagnostic hysteroscopy Hum Reprod. 2005 Jan;20(1):258-63. Epub 2004 Nov 18

GOLD STANDARD in OFFICE HYSTEROSCOPY TODAY

In terms of comfort• Respect the procedure• Preoperatives (setting of patient)• Drugs• Local anesthesia?• Local anesthesia?• Gas or H20 pression • Discharge of distension media• Time consuming

Pain evaluation

• Time• Age• Chronic pelvic painChronic pelvic pain• Previous cesarean sect.• Anxiety

Cicinelli E. et al Predictive factors for pain experienced at office fluid minihysteroscopy.J Minim Invasive Gynecol. 2007 Jul-Aug;14(4):485-8

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Pain evaluation

• 0 to 5 (lot of pain) or 1 to 10 points visual analogic charts

• Choice about antalgic preventionChoice about antalgic prevention

• Procedure succesfully and comfortly achieved

Pain management

• Nonsteroidal anti-inflammatory drugs• Intracervical or paracervical block• Topical analgesia… success rate over 90%…use of analgesia may enhance the success rate

• Readman E. et al. Pain relief and outpatient hysteroscopy: a literature review J Am Assoc Gynecol Laparosc. 2004 Aug;11(3):315-9

Hysteroscopy and menopause

• …various authors have recently proposed the use of hysteroscopy as a first-line procedure in the approach to the menopausal patient

• This could be defined as a change in strategy that has yielded very interesting results in terms of a better understanding of the appearance of the uterine cavity and the clinical value of small intra-cavitary pathologies, particularly in asymptomaticwomenwomen

• The time taken is comparable to that required for transvaginal sonography

Bettocchi S. et al Hysteroscopy and menopause: past and future,Curr Opin Obstet Gynecol. 2005 Aug;17(4):366-75

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Office polypectomy

• One-stop outpatient hysteroscopic polypectomy is effective in about 80% of patients

• Pelvic pain (7.5%) and polype size (8%) leading causes of failure

• Vasovagal reaction in 1.7% patients undergoing office endometrial polypectomy

Garuti G et al 2005Outpatient hysteroscopic polypectomy in 237 patients: feasibility of a one-stop "see-and-treat" procedure.J Am Assoc Gynecol

Office metroplasty

...in 93.1% of the cases (over 260 patients), office hysteroscopic metroplasty

was successfully performed during the same diagnostic procedure (no anesthesia)

presence of vascularized tissue, sensitive innervation, and the appearance of the tissue at the incision with 5 fr scissors screen a septate from a bicornuate uterus

Bettocchi S. et al Office hysteroscopic metroplasty: three "diagnostic criteria" to differentiate between septate and bicornuate

uteri Minim Invasive Gynecol. 2007 May-Jun;14(3):324-8

OFFICE’S COSTS

• …the mean charges, excluding professional fees, for the hospital were $1799 versus $62 for office hysteroscopy

• Hidlebaugh D. J Am Assoc Gynecol Laparosc. 1996 Nov;4(1):39-45 A comparison of clinical outcomes and cost of office versus hospital hysteroscopy

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ENDOMETRIAL CANCER

LOST IUD

LOST IUD

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60

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90

AGE DISTRIBUTION (314 patients) 03/04

Range: 23-87 years - Mean: 53 ± 12

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10

20

30

40

50

20-25

26-30

31-35

36-40

41-45

46-50

51-55

56-60

61-65

66-70

71-75

76-80

81-85

86-90

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100

120

INDICATIONS (314 patients)

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60

Climateric AUB AUB Asymptomatic Infertility Others

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120No previous diagnosisNo previous diagnosisEndometrial thickeningEndometrial thickeningMioma and fibrosisMioma and fibrosisEndometrial and CC PolypsEndometrial and CC PolypsTamoxifenTamoxifen

INDICATIONS (314 patients)

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Climateric AUB AUB Asymptomatic Infertility Others

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HysteroscopyHyst+biopsyHyst+polypectomyHyst+biopsy+polypecResettoscopy

What hysteroscopic procedure?

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60

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90 ATROFIC ENDOMETRIUMATROFIC ENDOMETRIUMHYPERPLASIAHYPERPLASIAPOLYPEPOLYPEFIBROSISFIBROSISNORMALNORMALCANCERCANCER

HYSTOLOGYHYSTOLOGY

DIAGNOSTIC CONCORDANCE

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ENDOMETRIALTHICKEN.

POLYPE FIBROSIS FIBROMA

SONOGRAPHYSONOGRAPHY

Success rate in office (314 pt)

• 88% (278 patients) (5 mm hysteroscope)• 28% (88 pt) operative hysteroscopy

• 1,85% (6 pt) experimented vasovagal effect• 0,9% (3 pt) cervicitis, endometritis

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COMPLICATIONS

• Complications may occur in diagnostic

• The complication rate in diagnostic hysteroscopy is low and was estimated by Lindemann (1989) to be 0.012%

• Complication rate for both office hysteroscopy and “hospital” hysteroscopy was respectively 1.9% and 4.2% (Hidlebaugh 98))

Complications may result from (Taylor & Gordon, 1994):

1. Anesthesia *2. Positioning the patient3. The distension media4. The surgery:

– Uterine perforation*– Haemorrhage– Vasovagal effect

5. Delayed complications:– Infection– Adhesion formation

6. Failure of resolution of the presenting symptoms

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Vasovagal complication

• During office procedure the pain is the main predictive syndrome

• In case of doubt control the hearth frequency rate (bradicardia, transpiration).( , p )

• The anestesists could be informed about the horaries of office hysteroscopies

Vasovagal complication

• Two thousand seventy-nine (279) women undergoing outpatient hysteroscopy without analgesia

• Rate of vasovagal syndrome was higher with use of a rigid hysteroscope (12/647 [1.85%]) vs. a flexible hysteroscope (3/1432 [0.21%])( [ ])

• Agostini A. et al J Am Assoc Gynecol Laparosc. 2004 May;11(2):245-7 Risk of vasovagal syndrome during outpatient hysteroscopy

Vasovagal complication• 112 consecutive women undergoing outpatient hysteroscopic sterilisation

without sedation or general anaesthesia• Successful bilateral tubal placement of the Essure microinserts was

achieved in 103/112 patients

• Transient vasovagal reactions occurred in 5/112 (5%) women

• Sinha D. et al. The feasibility, success and patient satisfaction associated with outpatient hysteroscopic sterilisation BJOG. 2007 Jun;114(6):676-83

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Damage to soft tissues

• It is the responsibility of the surgeon to ensure that there is no injury from moving parts of the table to the patient's soft tissues or hands

• No part of the patient is in contact with metal parts of the table because these can act as return plates for electrical energy and burns can occur at the point of contact

Carbon dioxide• Cardiac arhythmia may occur with diagnostic

hysteroscopy• The complication should be extremely rare if the

correct insufflator is used• The hysteroflator delivers CO2 at a rate of not• The hysteroflator delivers CO2 at a rate of not

more than 100ml per minute whereas the laparoflator can deliver 1-6-10 litres in the same time

• A laparoflator should NEVER be used for hysteroscopy

• It is rare for CÓ2 to produce any side ff t if b li f l th 400 l

Carbon dioxide

effects if gas embolism of less than 400ml occurs

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LATE ONSET COMPLICATIONS

Infection• Acute pelvic inflammatory disease is rare following

hysteroscopy• This may be prevented by prophylactic antibiotics y p y p p y• The diagnosis is made by the presentation of the

classic symptoms and signs• Treatment should be by appropriate antibiotics

following culture of vaginal swabs and blood

Hysteroscopy: a technique for all?

• The hysteroscopies were successfully performed in nearly 95% of cases by 362operators (mean 13.8 hysteroscopies per operator) with different levels of expertise.

• A high level of expertise is not a prerequisite to performing hysteroscopy on an outpatient basis.

• Recent advances in technique and instrumentation facilitate this approach and might encourage greater adoption by the wider gynecology community.

Di Spezio Sardo A., Magos A. et al Hysteroscopy: a technique for all? Analysis of 5,000 outpatient hysteroscopies, Fertil Steril. 2007 May 4

Hysteroscopy: a technique for all?

• The ESGE offers clears indication to future hysteroscopists concerning the attempt of a safe level of knowledge.

• - For basic level attempt

• 1) A minimum of 50 of the following procedures• Simple hysteroscopy• Target biopsy, IUD removal, or minimal adhesions (

no use of laser or electricity)

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Hysteroscopy: a technique for all?

• Only one hysteroscopy per week is required to attempt a basic european levelp